Building a Brain Tumor Center

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- Colleagues and friends, thank you for joining us for another session of the Virtual Operating Room. My name is Aaron Cohen. Our guest today is Dr. Ric Komotar from University of Miami. Ric does not need any introduction. He is professor of neurosurgery. He is director of the brain tumor program at University of Miami, as well as the residency program director. He is truly an incredible rising star in neurosurgery. I'm so proud I've followed his career very closely. He has developed one of the most comprehensive and busiest brain tumor programs in University of Miami. And I really would like to learn from him about the pearls and pitfalls of establishing such a busy and successful brain tumor program. Ric, it's truly been an honor knowing you. I've really followed your career closely. And I sincerely appreciate your contributions. And today we would love to hear about your pearls and secrets in developing brain tumor programs. So with that, let's go ahead and thank you.

- Well, thank you Aaron. I really appreciate you inviting me on here. I've obviously been following your work as well. Incredible what you've done with this atlas and this OR and this virtual grand rounds. So again, it's really an honor to speak. Just like you said, we're gonna be talking about building a brain tumor program. And even though the title says brain tumors, it's really applicable to all of neurosurgery. Spine, vascular, functional, really doesn't matter. These principles are applicable to all of medicine generally. And I would say that this talk is mainly for residents, fellows and the junior attendings. People who are starting out 'cause you spend seven, eight, nine years training and you learn how to take care of the patient, which is obviously the most important thing. But you never really learn how to get the patients. And that is absolutely just as important as taking care of the patients. So you figure that so much attention goes into learning neurosurgery, but none of it goes into the business aspect. So this is some of the most important information that any trainee is gonna learn. Basically seeing how to get the patient, not only take care of them. So again, really based for the junior attendings who are really trying to build a program here. So the first question I guess we'll talk about is, what's the definition of a practice? And that is exercise of one's knowledge to treat disease. But what does it mean for us neurosurgeons? It means the volume of patients that you're gonna be taking care of. Who are you gonna be evaluating? Who are you gonna be operating on? But the next question is, why should physicians strive to build a practice, right? What is the benefit? Is it worth the time and effort? And this is exactly right. It takes time and it takes effort, it's not easy. And like I said, it's never taught in residency, but it's absolutely critical for success. So one of the benefits of having a high volume practice. So if you're in private practice, it's pretty obvious, right? That's the revenue that you're gonna be generating. You're running a business, the cases fuel your enterprise. But in the academic setting, the benefit is gonna be a lot less clear. Many of us are on salary, there's not a direct financial correlation. So really we all know that physicians in academia can survive despite "Being in the red." Which really brings us to the next question and this really is the most important question. Why is it important to have a high volume academic practice? Like I said, mainly salaried, minimal financial incentive usually. We've all worked hard as a resident and a fellow and now's the time to relax, right? I remember being a resident and thinking to myself, these attendings are on salary. It doesn't really matter how many cases they do. I will never work that hard. I remember telling myself that. And I can tell you that I've worked harder now as an attending than I ever worked as a resident. So for all the residents out there, the work only gets harder, it gets better, but it gets harder and you work harder 'cause it's now yours, it's your practice, it's your program. And so now there's more ownership of it. So this is the most important slide of the entire talk. And I really can't emphasize it enough. If you can only look at one slide, this is the one to look at. And that is that volume is power. The moment you understand that volume is power, you'll understand why it's important to build a busy clinical program. So number one, volume is gonna be expertise. Just like playing a sport. If you play golf once a month, just like me, you're gonna be terrible. If you play golf every single day, you're gonna be good at it. Same with surgery. If you're seeing these complex cases often you get more comfortable, you have better outcomes and you really become an expert at these cases. No one becomes an expert by doing one case a month. You do it by doing it over, over and over again. Volume is gonna be training. So if you're gonna produce the next generation of leaders in the field, your residents and fellows need to see these cases early and they should really see them often. And that's important, it's repetition. It's getting the junior residents and the mid-level residents to be just as good as the chiefs at a very early stage. Volume is gonna be data, it's gonna be research and it's gonna be clinical trials. So especially in brain tumors, if you're doing research on outcomes, if you're doing clinical trials, you need to have the volume. Very difficult to run clinical trials and accrue patients if you're only doing one case a week, one case a month. Volume is also gonna be reputation regionally, locally and nationally. And then most importantly, volume is gonna be institutional and programmatic support. And by that I mean that no matter where any trainee finishes, no matter what junior faculty they are, they're gonna be asked to build something at whatever program they go to. And people go to a program and they have a lot of asks, I need better OR time, I need more equipment, I need a nurse practitioner, I need ancillary staff. Everyone has asks that they want in order to build their program. And you can imagine that these programs have many, many asks, way more than they can support. And no one's listening to you if you're doing one case a week, but you start doing five tumors a week, 10 tumors a week, 15 tumors a week, 20 tumors a week like we're doing here. Now you have control of the volume, you control a tremendous amount of revenue for the hospital. And when you go to administration and you ask for support, they're going to give it to you no questions asked. So the point here is, instead of asking and then producing, what I recommend doing is what we did down here. If you're gonna start a program, produce, prove your worth, show your value and then everything will fall into place. Then when you ask, you will get everything you want just like we've gotten down here. So absolutely the person or the program that controls volume, that controls the patient referral base, ultimately controls the institutional and programmatic support via the volume. So how do you build volume? Obviously a very complex topic, it's gonna be tough to cover just in this one talk. But as I said before, really requires work, right? Everyone starts a job and they want to know where are my case is, where my case is coming from. My OR is not full, why aren't they giving me cases? You gotta put in the work. If you just go to the operating room and you go home, you will never build a busy practice. Surgery is the easy part. And I tell our residents this all the time. You're in the operating room, no one's bothering you, no one's calling you, no one's texting you, you're with the residents and fellows you're operating. That's the best part of the day, that's the easy part. You have to remember to yourself that there's a lot of options out there. A lot of talented surgeons. All of us neurosurgeons, think that we're God's gift to neurosurgery. We think that no one can do it as well as we can. The reality is a lot of people can do what we can and perhaps even better. There's a lot of talented options out there. So always ask yourself, why should patients come to you? The moment you think that and you realize that your surgical skills are not your competitive advantage, a lot of people are able to operate well. There's a lot of great surgeons out there. So what is your competitive advantage? What's gonna make patients come to you? And as soon as you take that mentality, the rest of the principles all fall into place. So the three A's I know everyone's heard about these, but we'll go over them again. Availability, this is the predictor of basically all the referral patterns period. Plain and simple. You gotta be available. And that's not office, that's not fax, that's phone, that's right here. It's email, cell phone and text 24\7 365. You can disconnect when you go on vacation, but it can't be permanent. It can only be for a couple hours. It's very, very difficult. In this day and age, people expect a response very quickly. If it's a workday, they expect a response within minutes unfortunately, if it's a weekend within hours, within vacation, a couple days at most. But you gotta be available, you gotta answer your phone. And the doctor that's most available is gonna get most of the referrals. Number two, how affable are you? That's just an obvious principle. You can't be a jerk. People have to like working with you. It doesn't mean that you have to be overly congenial, but you just can't be a jerk. You have to be friendly. People have to enjoy working with you. If people enjoy working with you, they're going to want to send you patients. They're gonna wanna work with you again in the future. And lastly, actually least important amazingly, is how able you are. We all know bad surgeons that have busy practices and that's 'cause they have the first two A's. Now if you can do all three A's, that's when you can really dominate. So how do you build a program? A program is obviously much bigger than just a practice. And we're gonna go over all of these in the setting of building a brain tumor program. But again, this is applicable to all the neurosurgery, doesn't really matter what specialty. And it's even applicable to things outside of neurosurgery, outside of surgery, outside of medicine in general. Number one, targeted faculty recruitment, aggressive referral network development, community outreach, expanded catchment area, facilitated referrals, expedited office appointments, fostering collaboration with the community, social media internet presence. And finally, superior clinical outcomes. And like I said, we're gonna talk about this in the setting of our brain tumor program here at the University of Miami, which we started back in 2012. Our goal was to build a comprehensive brain tumor program. All the pieces were here, but it had not been put together yet. So what were our challenges? It was number one, to train future leaders, start a brain tumor fellowship, bring in surgical innovations and techniques that are on par with the other major brain tumor programs. Start a brain tumor bank and database that's absolutely critical to any academic brain tumor program. Ramp up clinical trials and translational research. And finally, like I said, priority number one, two, and three case volume. Once you build the case volume, everything falls into place. It's impossible to do any of the above unless you have case volume. So that was really our goal from the very beginning. What were the challenges? So back in 2012, the University of Miami had bought the private hospital across from Jackson. And that was the flagship hospital. That was the University of Miami Hospital. But it had a lot of challenges, even though that was the brain tumor headquarters had a lot of challenges. Number one, a small ER. And so why is that a challenge? Well, so for example, Jackson Memorial, which is just across the street, very busy ER, there's at least one or two operative brain tumors that come through there nearly every single day. So if you just rely on the emergency room, you're actually gonna have a pretty busy practice. And those are guaranteed cases you haven't worked for those, they're coming through the emergency room, they're kind of captive. So we were trying to build a program, but there was no emergency room. So it was very small. So we didn't have these guaranteed cases to help us ramp up. The staff, this was a small private hospital prior to us buying it. So we had no experience with brain tumors. The nurses, the ORs, the techs and the consultants had no experience how to take care of brain tumors. And finally, this used to be a private hospital. So these very strong networks that were formed in terms of their referrals, we had to crack into these referral patterns and change how these doctors viewed academics versus private practice. So step number one, targeted faculty recruitment. No matter what program you're building, as I said, it doesn't matter what division of neurosurgery it's gonna be. If you're gonna build a program, you need a clinical workhorse that needs to be your first hire. Everyone talks about research, administration, 50/50 person, all of that is key and you need that eventually. But your first hire should not be a researcher or someone who's 50/50, 'cause you don't have the volume yet. You need a surgeon that's 100% focused on expansion. Then once you have the volume, everything else falls into place. Aggressive referral network development. So people need to know about your program, right? Just because you start a program, you need to market, you need to do PR, you need to educate the public. So our goal, for example, once we started our comprehensive brain tumor program, was to raise awareness of this program throughout South Florida. Doctors didn't know about the UMBTI, which is the University of Miami Brain Tumor Initiative. Went on a mission to inform all South Florida about what the UMBTI was about. So we googled South Florida hospitals. We found 92 hospitals from Key West to Treasure Coast out to Naples. Some of these hospitals were small psych hospitals. Others were major medical centers just like Baptist and Mount Sinai. We reached every single one of these hospitals and we asked to speak at one of their CME events. Every single hospital has to have CME events, either grand rounds, tumor board, some type of CME event every single hospital has to have. So we really inquired trying to speak at these events, talking about what we were offering. We were allowed to speak at 77. And so over a year and a half, we gave 77 talks at these local hospitals that were anywhere from five minutes from us over three hours away. What did each talk really emphasize? Three A's of course that we were always available, affable and able. What we were doing differently at UM from the community and from other academic hospitals, surgical techniques and our excellent outcomes. I'm not gonna belabor this because this has been talked about in many other talks and these are the surgical techniques that all the major brain tumor centers across the country have. And the point of the slide is that, if you're gonna be a top ranked brain tumor center, doesn't matter if it's in California, Florida, New York, Indiana, it doesn't matter. You have to have these techniques. These techniques draw the patients in. The vast majority of brain tumor patients don't come from radiation oncology, they don't come from neuro-oncology. They come through neurosurgery for the vast majority of those referrals. And so you have to offer these cutting edge techniques because patients will seek this out. Patients are educated, they will Google, they will know what the latest and greatest is and they will seek it out. It may not even apply to them. So for example, let's talk about laser ablation. Laser ablation is a relatively new technique. We are one of the pioneers in that technique. We actually have the highest volume laser program in the country. But for every 10 people that come to me wanting a laser who have read about laser, maybe one needs the laser and nine get a regular open surgery. So that's an example of how the technology draws patients in. Even if it doesn't apply to them, you have to be able to offer these techniques if you're gonna draw the well-educated, well-informed patients. And what it each talking with? It ended with perhaps the most important part of the talk. How to get their patients seen at the university. Gave my personal content information. And many of the old school doctors don't like to do this. Many doctors don't like giving out their email, they just abor the idea of their cell phone being out there. My response to that is in the year 2022, you have to give out your personal information. If you are going to put up a wall and you're not gonna give access, your referral pattern is gonna be crushed. In this day and age you have to. So if you're gonna complain about your volume, if you're gonna want your volume to be more, if you wanna build a high volume practice and you wanna be successful, you have to give out your personal information. Not to patients, but to doctors so that they can contact you. And I always say this, is that having contact and having access is everything. Access is key to building a practice. The more you break down walls and you give access to other physicians, they all wanna send to you. They just don't know how to do it. So again, very important that you give your own information out. How can these doctors reach you if they have a patient that they want you to evaluate? Next step reaching out within the community. Not just doctors, you need to look and it's not just okay that the patients know about you and that the doctors know about you. You have to reach out and really increase your footprint through looking at these support groups. So in Florida there's really four major brain tumor support groups. Florida Brain Tumor Association, Voices Against Brain Cancer, Pap Corps and Women's Cancer Association. These four support groups have a major impact in terms of where patients get referred. So what did we do? We joined all of their boards of directorship, spoke at their gala events, got to meet their patients, meet their leadership. Because I can't tell you how many times someone will be diagnosed with a brain tumor. They have a friend of a friend who's part of the Pap Corps or Women's Cancer Association. Who do I go see? If you form these relationships and you form these networks, you're going to get additional referrals because this will increase your overall footprint. You have to look past just the referring physician and realize that these support groups play just as important of a role as the referring physicians. Expanded catchment area. So when you're building your practice, you have to identify gap zones. You don't wanna spend all your time trying to build a practice in an area that's already saturated by your own colleagues, by your own department. You have to do the research and all of this is available in different databases. You have to look and see what areas are saturated and which ones are not. What's the biggest referral potential, what's the best opportunity for growth? So for us back in 2012, Dade County, we already had a monopoly on Dade County brain tumors would've been silly for me to spend time in Dade County 'cause that was already saturated. Very quickly I realized that Broward and Palm Beach, which are just an hour to two and a half, to even three hours away, all these patients were being diagnosed with brain tumors. Any patient who had a brain tumor was immediately being sent up to Duke. No one was getting a second opinion, no one was even being seen locally. No one was going to Miami, Gainesville, Tampa, Jacksonville, everyone was going right up to Duke. And Duke is great, but why not educate these people that there's another option that is also excellent that is driving distance. So we really went on a mission and spent many, many hours, many, many days, many, many weeks really going up to Broward, driving up to Broward Palm Beach, meeting the neurologist, meeting the oncologist, meeting the primary care doctor, speaking at their events and letting them know, "Look, Duke is great, Duke is fantastic, but if you want a second opinion, if you want a local opinion, here's my cell phone, here's my email, text me, call me, email me anytime." Very quickly we just cut Duke off and all the referrals started coming down to us. So that's an example of that time if I had spent it in Dade County, really would've not have been productive. But that same time in Broward and Palm Beach was really very productive because that area had a tremendous growth potential. And that was identified early on when we looked at the numbers through administration. The next step, how do you facilitate referrals? So it's not enough that you educate doctors and your patients about you. As I said, you gotta be available not just your office phone or fax. In the year 2022, this is completely irrelevant. No one calls people's offices, fax. I don't even know if I even get faxes. I don't even know my own fax number. So in the year 2022 to say that you're gonna send someone a fax is completely archaic 'cause you get a fax, you read it, you want to contact the person, now you gotta call their office back. They're not in the office now you're playing phone tag. Absolutely ridiculous in the year '22. It's all cell phone, text and email. And if you don't like it, I'm sorry, that's the way of the world. As I tell our residents, our fellows, you either get off the track or you get on the train because honestly this is the way the world works. You have to be available and you have to be answering your cell phone, you're text and your email pretty much at all times. And that's what it takes in order to be successful. As I always say that the most able doctor does not always get the referral, but the most available doctor does. Hopefully these two really go hand in hand. And that's what we've done here. But again, you could be able, but if you're not available, someone else is gonna get the referral. So it's really not enough that you're available, right? Just because you're available is great. But what's the next step? What's the final step? You need to make the referral seamless. So for example, if a doctor calls my office, "Hey Ric, I want you to see John Smith for me." The answer of, "Oh great, have them call my office." That's the wrong answer because they could have gotten your number off the internet or Google, you've wasted their time, they've wasted your time. Now they have to call some central number. It's gonna get lost at least here. It'll definitely get lost. It'll get scheduled four weeks out and you're gonna lose the patient. So you haven't helped anything. You haven't helped that doctor, you haven't helped you and you haven't helped the patient. So the answer needs to be, "Sure, give me the name and number of the patient and my office will then expedite." This is the correct response. The doctor gives you the name and number. Now he knows that, that responsibility for that patient is now in the hands of a specialist. You now control that referral and you can make sure that referral gets seen quickly. Next expedited office appointments. So you've now facilitated that referral. You now have that information. But now you need to expedite the office appointments. This is where brain tumors are different than let's say spine. Many spine patients have had back pain for months, years. They're willing to wait in order to see the person that they think is the best. But brain tumors are different. Doesn't matter if it's a one centimeter convexity meningioma, it's a new diagnosis. Quite frankly, it's the scariest diagnosis you can get. It's a brain tumor. People think they're gonna die. So we see all new patients within 48 hours. And you don't have to schedule surgery quickly, but you have to see them quickly. And it doesn't matter if they have to wait in the office. As long as they see you. So we see patients five days a week often just during our lunchtime or in between afternoon surgeries. And my staff will tell patients, "Dr. Komotar is operating today, you may have to wait up four hours." Patients do not care. They just wanna be seen and they wanna be evaluated and they wanna know what's going on with their newly diagnosed brain tumors. So you do have to understand that patients with brain tumors, absolutely 100% will not wait. I don't care how good you are, I don't care your reputation, I don't care about your fellowship training or your outcomes. If you make a brain tumor patient wait, they will go elsewhere. So you have to somehow make sure that patients don't wait too much because that will basically obviate any other work that you put into it. You can go out, you can promote, you can make sure everyone knows about you, you can get the information and then if your office tells them, "Yeah, Dr. Komotar will see you in three weeks with your newly diagnosed brain tumor." They're gonna find someone else guaranteed. So absolutely have to expedite. Fostering collaboration with the community. This is absolutely critical. If you think about it, right? The goal is to integrate the academic center into the community. The vast majority of patients do not come from academic centers. They don't come from within the academic center. So I would say that, here at Miami, how many brain tumors come from within the institution, it's probably 10% of the overall brain tumor volume. In the surrounding community, that's where 90% of the referrals come. So if you're gonna silo yourself off and you're not gonna integrate with the community, just imagine you're basically blocking off 90% of the referrals. That limits what you can build tremendously. So the goal is to integrate your academic program into the community. And again, if you think about it, what referring physician wouldn't want their brain tumor patient seen at an academic institution, right? We have the best surgeons, we have the best outcomes, the best techniques, the biggest specialists, the most dedicated, comprehensive patient specialized care. But again, as I said during the first couple slides, put yourself in the shoes of the referring physician. What are the roadblocks? Number one, availability. They have no idea who to call. Zero idea, right? Oh, I'm gonna call 1-800 Miami Hurricanes or whatever the central scheduling line is. So that's not gonna work. They have no idea who to call as opposed to calling their friends in private practice who they have their cell phone, they can call their local neurosurgeon who will answer the phone immediately and see them right away. Access again, in general at the university, it's very difficult to make appointments. So if someone out in the community has a brain tumor and they wanna refer it to the academic center, not only do they not know who to call, but once they call, there's no access, and access is key. That patient's gonna be seen weeks or months down the road. Next, no one is gonna communicate with that referring physician or at least they don't traditionally communicate. Meaning that a private physician who refers a patient to the university will most likely never hear back about what happened to that patient. Again, put yourself in the shoes of that referring doctor. This is your patient, you send it to the university, you never hear back. That's not a good feeling and I wouldn't send a patient there 'cause you wanna know what happened to your patient. That's just common courtesy. And finally, continuity of care. Most patients who come from the private practice setting and go to the university get gobbled up by the university. That's the black hole effect. Meaning that if an oncologist out in the community has a patient with breast cancer, she's diagnosed with a new breast metastasis that has gone to the brain, she gets referred to our department of neurosurgery, we operate, take out that metastasis and then referred to a university oncologist. You've now lost that patient or you've stolen that patient from the private practitioner who's also trying to build a practice for the same reasons you are. She or he is losing business, they're not gonna refer to you again. So what are the solutions? Always be available. Answer your phone, answer your email, answer your text. Don't rely on your central scheduling. Easy access. Patients seen within 48 hours. Don't make it months and months to see you 'cause you're gonna lose patients. Constant feedback. A simple text or phone call back to the doctor, "Hey, saw your patient, this is the plan." And finally the patient always goes back to the referring physician. This is practice building 101. If you don't understand this concept, you've got major problems. But the patient always goes back to the referring physician. Always. And if you can incorporate your academic center in the community, that's when you really get an exponential growth in your case volume, because you're tapping into an entirely different referral base, not just within your siloed academic community. So how do you network? Everyone can do it differently. I store my contacts on Outlook. This way they're stored on the cloud. I can access them from my computer, my phone. Doesn't matter anywhere in the world, I have access to my contacts. Currently at approximately 8,000 physicians here in South Florida. Having this networking allows me to constantly update physicians. Email and text before the surgery, after the surgery, during follow-up, MRI collages, easy send MRIs showing the pre and post-op pictures. As I said, fax is completely pointless. You should just remove that from your mentality. Fax in this day and age does not work and you might as well just send smoke signals. You really wanna open up lines of communication. That's the goal here. You have to realize that the easier you make it for people to contact you and again, I mean doctors, not patients. The moment you drop down the barriers and you increase access for other doctors to reach you and you're a sub-specialist, they're going to refer you patients. And it allows you to communicate with them, right? So instead of faxing or phone calling, right? I text a lot of doctors. And so for example, if I operate on a pituitary adenoma and the endocrinologist is from the community and they wanna know is the patient in DI, what's the hydrocortisone at? Yes, being discharged, sodium is this, it allows you to have a discourse, have an open communication and it's better for the patient. It's better care for the patient, better continuity of care. And then at the end of the day, you really have to communicate and you have to network such that your reputation as a specialist who's available grows. So this is an example of just a very simple post-operative text that I'll send on post-operative day one. Joe Smith doing well, no issues. Neuro intact, home today. MRI confirms gross total resection of his large bifrontal meningioma, Ric Komotar. This took me, I don't know, 10 seconds to dictate and write. And then my fellows put together this MRI collage, which just again, takes him less than three or four minutes. Pre-op images, post-op images. I send this text to the doctor. He's never gonna send another brain tumor anywhere else, but to you. He knows exactly what's going on with his patient. He sees the film, which even for a primary care doctor, it's impressive. They can see what exactly happened with their patient. They feel involved. And so not only does the doctor feel involved, not only is he always gonna refer you patients, because again, he's part of the team. At the end of the day, it's better patient care. The doctor knows to see the patient right away. They see him in follow up. The patient is not lost through the cracks. So a simple text like this goes so far way more than any phone call or any fax. So this is an example of what networking can do. This is a patient that I saw just a few years back from Orlando, which is about five hours from us here in Miami. And it was an MRI and on the report it just says, "Large right-sided mass to go see Ric Komotar at the University of Miami." In the MRI report on a patient five hours from me. So of course this obviously shocked me. And so what did I do? I contacted this MRI center, which is the single largest MRI center in all of Florida. I spoke to this doctor, I said, "Look, I appreciate this referral." I kept in touch with him. I let him know about the surgery. I let him know what the tumor was. Was it meningioma? Was it a metastasis? Was it something different? I kept him posted. Then I took up a trip and I drove up to Orlando and I met all of the radiologists in this MRI center. So what happened now? Now every single brain tumor that comes out of the largest MRI center in Florida immediately says, "Go see Ric Komotar." So these patients, you're not gonna lose them to the referring doctor. You're not at the whim of the oncologist, you're not at the whim of the insurance company. These patients come out and they're like, "Wow, I gotta go see Ric Komotar in the MRI report." So this is an example of networking. You form these networks, these doctors trust you, they know the work you're doing, they know that you're gonna communicate with them, you're gonna let them know, and it really is better for the patient. So this is an example of just your work and your quality of work is only as good as how well you communicate with other doctors. So this is the step-by-step of how I do my referrals. Everyone can do it differently. And obviously there's no right way, wrong way. This is just my way to do it. Number one, I get a call, text or email. I would say 80% of my referrals come through my cell phone. I get the name and number always. And actually now doctors, a lot of doctors know my routine. So they won't even call me. They'll literally send me a text, "Ric, I need you to see John Smith with a pituitary macroadenoma, here's the number." That's it. They know that that's all I need. I then forward that to my office schedulers. My office knows every new patient seen within 48 hours. I see the patient, I make a plan, I relay that back to the referring doctor, email or text. I email or text after the surgery, surgery was done, went great, gross total resection home tomorrow or what have you. I then sent an email and text upon discharge, patient doing great, going home today. Here are the MRI images, we'll see them back and discuss at tumor board or again, what have you. And then finally I see him back in follow up, simple email or text, saw your patient back, pathology shows A, B, C or D. Here's the plan. Chemo, radiation, follow up, again, what have you. This is a lot of work. I'm not gonna downplay it, this is a lot of work. But if you're organized and you're focused and you're diligent, this is definitely doable within a regular workday. Social media, internet presence. Absolutely critical in the year 2022. So just like fax is completely irrelevant, social media is very much relevant. So again, there is a big generational gap here in that a lot of the older physicians don't wanna do this. They feel like, "Oh, physicians shouldn't have to market. They shouldn't have to do PR." Time to wake up, medicine is a business. We don't like to think of it that way, but it's a business. You are selling a product, you're selling brain surgery, you're selling brain tumor surgery. And unless people know about you, it doesn't really matter how good you are or really what your outcomes are. So these are the big social media platforms and the internet websites, health grades, Press Ganey, Instagram, Facebook, Twitter, I would pick one. I think doing all three is a little bit excessive. I pick Instagram. But again, I would say pick one and really focus on it. University webpage and your professional webpage should you need it. The reason why this is so important is that, I always compare shopping for a neurosurgeon is like shopping for a bottle of wine, right? I know nothing about wine. So if I have to go buy wine, I go to the liquor store and I buy the coolest looking bottle of wine. I have no idea if it's good or not, but I buy the best looking bottle. What's the coolest looking colors, pattern, whatever. Same thing when it comes to shopping for a neurosurgeon. 99% of patients have no idea what makes a good neurosurgeon. They don't understand fellowships, they don't understand, "Ooh, you subspecialize." They have no clue. But they're gonna look at your website and your website better accurately reflect what you have accomplished and what you do that is so special. So I'm not saying lie, but what I'm saying is you need to accurately reflect the type of physician you are. So for example, if you're doing cutting edge research and you just published a paper in nature, that needs to be on your website. Otherwise, no one's gonna know. If you just ran a huge clinical trial, which changed the way a certain disease is treated, that needs to be on your website. If you're pioneering a new technique, that needs to be on your website. All these things make a difference because otherwise patients don't know. And anyone who's referred to you, the first thing they're gonna do is, they're gonna Google you. And whatever comes up on Google is how they're gonna make a decision to go see you. And many university websites are very limiting. Really depends on what template your university website has. If it's overly limiting, then I really do suggest starting a professional webpage where you're able to showcase more of what you do. Videos, patient testimonials, all that stuff matters. And it's not wrong to do that. You're basically educating the public on why they should see you. So take the time, make sure that your internet and your website presence is accurate and it really does reflect the type of high quality physician that you are. Finally, superior clinical outcomes. Everything I said up to this point is critical and yes, it's all true. This all helps you build a practice. But at the end of the day, patients will ultimately be your biggest referral source. In this day and age everyone knows someone who knows someone who had neurosurgery of some sort. So you really need to make sure that your patients do well and that your patients are happy because they will go out in the community and they will sing your praise like no one else. Again, put yourself in the shoes of your patients. If you have brain surgery and a tumor comes out and you do well, you're gonna go around and you're gonna tell everyone how amazing this hospital, this program and this surgeon are. So here are the steps. Keep patients as your first priority. And by that I mean that in academic neurosurgery there's a lot of "Distractions." And by that I mean there's administrative duties, there's educational duties, mentoring, research, organized neurosurgery with meetings. All that stuff is important, it's 100% important. I do a lot of it. And it really is key to being an academic neurosurgeon. But no matter what happens, remember why you did neurosurgery, you did neurosurgery to take care of patients. And so you really have to always keep clinical work as your first, second and third priority. Keep complications to a minimum. whether you like it or not, your reputation as a surgeon is formed within the first three years of practice. Period, end of story. That's the harsh reality. And by that I mean you come out of a great program, you're well trained, but you're a little bit too aggressive early on. You have a couple of avoidable complications. All of a sudden people label you a hack. And it's very hard to outwork that. However, conversely, if you come out, you're well-trained, you're safe, you're conservative, your outcomes are excellent, people are gonna give you carte blanche. They're gonna say, "Hey, this guy or this girl is an excellent surgeon." And then later on people will cut you a break when you have complications because everyone has complications. No matter who you are, if you don't have complications, you're either lying or you're not operating one of the two. So you have to avoid the avoidable complications. We all have complications, but we all know the ones that are kind of unavoidable, that are just part of the game. And ones that you can avoid. Keep your outcomes favorable. Outcomes are your cache. You're doing neurosurgery and your cache is not your research or your leadership or that you're a program director. Your cache are your outcomes. That's how you're judged. People are gonna look at you and say, "What is this surgeon's outcomes? How do his patients do?" So always keep outcomes as your main priority and make sure that they're favorable. That's gonna reflect on you down the road no matter what you do. Round twice a day. This has been a little tough now with COVID, but this is still critical. Meaning that you can do the world's best surgery. But if you never see the patient, they're not gonna speak highly about you. You could take out the world's smallest brain tumor, but you round twice a day, you spend 30 seconds to one minute on the bed. You basically just make sure you sit down on the bed, spend that 30 seconds there, talk to them, make sure you answer their questions. These patients will speak about you so well. So I think having that interaction, having that patient contact, is not only gonna make your outcomes better because you're gonna find complications, you're gonna find complaints that you otherwise wouldn't find. But it also makes sure that your patient satisfaction scores are through the roof. And patient satisfaction scores again, whether you like it or not, this is a business. If you're running a business and your client satisfaction scores are low, that business is gonna go outta business. Same with surgery. If your patient satisfaction scores are high, it's gonna lead to more patients. So as I say, happy patients means more patients. Really need to be patient focused as you decide what your priorities are. So wanted to look at the Florida Health database. Wanted to look and see what was our growth in the last decade. Benchmarks versus other competitors here in Florida. This is as I said, a very large database looking at demographics, all the procedures, ICD-9, CPT codes. And this is our growth. You can see here excellent growth. 2011 doing a poultry 200 cases. And then just two years ago hitting 1200, we're now over 1300 brain tumors, which makes us probably the busiest brain tumor center in the country. And this growth right here is an example of just everyone buying in. All the doctors, all the nurses understanding how to build a program, how to build a practice, patient satisfaction, patient-centric care, all the issues that go into building a business, which is what medicine is. If everyone buys into it and everyone understands that paradigm, that's when you can get this kind of exponential growth. Percent of cranial surgeries in Florida. So you can see here back in 2011, we were doing less than one half percent of all cranial surgeries in Florida. By 2018, nearly 5% of all cranial surgeries in Florida. This is an increase of 1000% in just seven years. So this number may not seem like a lot, but if you think about it, Florida's the third most populous state in the entire country. For every 20 cranial surgeries or one out of every 20 cranial surgeries in the entire state, including shuns are being done at our private University of Miami Hospital. So it's really just a mind boggling number. Distance traveled. You could see here that back in 2006, average distance was only five miles. Meaning that people were coming just around the block basically. But three years ago, four years ago now, average distance, nearly 50 miles, this is an example of the marketing, the outreach, educating the public, educating doctors, finding gap zones, and then patients going back and then speaking highly about you. So this is showing that you don't wanna be a local destination, you wanna be a regional and really a global destination for whatever specialized program that you're trying to build. Where did the growth occur? Nearly 25% of the growth was outside of South Florida. Again, think big. Don't focus locally on just the local hospitals. You gotta look on the entire region because if you limit yourself locally, again, you are really capping yourself off and you're limiting what you're ceiling is gonna be. We've grown along I-95, which is up this way. And then we also expanded to the West Coast and up the West Coast of Florida. A large percentage of our patients come from the West Coast of Florida. So again, did not limit ourselves just to the East Coast. Really went to the West Coast of Florida and then out to the panhandle. What did the other numbers show? Well over 1200 brain tumor surgeries per year. As I said, now over 1300 brain tumor surgeries per year. By far the busiest program in the state and most likely the busiest program in the entire country. We've done 35% of all brain tumor surgeries in Dade County. 20% of all brain tumor surgeries in Broward and 20% of all brain tumor surgeries in Palm Beach. And then, most important, what is the trickle effect of this volume? 'Cause as I said, your hires need to be clinically based. You have to have a clinical workhorse and volume is where everything starts from and then it generates a comprehensive program. So what did that look like for us here in Miami? So again, 200 cases a year, very poultry, we're now almost 1300 cases per year. We went from conventional surgical techniques to bringing in the most advanced cutting edge surgical techniques. We really had a very unreliable neuropathology back in the day. We were pressuring the cancer center to higher better neuropathologists. Not gonna happen when you're only doing 200 cases a year, but you start doing over a thousand cases a year. That puts a lot of pressure on the cancer center. And as I said originally, if you're controlling that volume, you control the revenue. So the administrators are gonna be listening to you because at the end of the day that gives you cache. And so based on our volume, we were able to bring in world-class neuropathologists. We only had one medical neuro oncologist. We now have four dedicated medical neuro oncologists. Actually hiring two more and so we're gonna have six. We had no brain tumor bank database. We now have one of the largest in the country with over 3000 cases. We only had one clinical trial. We now have 15, which is on par with all the other major brain tumor centers. We had no dedicated brain tumor researchers. We now have four and actually are gonna have five next year. Dedicated federally NIH funded brain tumor researchers. We only had two brain tumor publications, currently, almost 50. This shows how we've gotten the residents involved, the fellows involved and how it's a real team effort. We had no fellowship. We now have one of the few CAST approved brain tumor fellowships. And as I said at the very beginning, we identified a growth opportunity. And once you identify that growth opportunity and you maximize it, that's when you can really have a comprehensive program and a real center of excellence. Obviously this is a huge team effort. This is far from a one man show. Everyone here bought in, everyone here is a critical part of the team. Everyone from the surgeons to the neuro oncologist to the neuropathologist. But I really do wanna focus most of it on the fellows. We've been blessed here to have some absolutely exceptional brain tumor fellows. These fellows are the engine that makes our brain tumor program run. These are the reason why we can run multiple rooms. Why we can pump out 50 papers a year, why we can get grants, why we can run clinic five days a week. And these are the future of neurosurgery. These are all future leaders. These are people who have gone into academics and are leading their own programs. So I just wanted to give kudos to all of our fellows who we've been lucky enough to have trained here in Miami. I just wanted to put a quick plug here. Dr. Eichberg, who's one of our outstanding senior residents and myself put this book together, which is "The Business of Brain Tumors" forward by Bob Spetzler. And basically this goes over everything that this talk just covered, but in obviously much more detail since it's a book. This is very light reading and strongly recommend that anyone finishing training, again, doesn't matter if you're doing brain tumors, anyone finishing neurosurgical training. These principles are absolutely critical. And they're never taught during residency or at least they're not formally taught. So this book would definitely give people a jumpstart in understanding. Yes, it's important to be a good neurosurgeon, that's by far the most important. But you gotta understand all the factors that go into building a practice, building a program or else you're gonna be stunted. So with that in mind, thank you so much for your time. And again Aaron, thank you for having me. It's a real pleasure.

- Ric, thank you for the great lecture. Great pearls. Without a question critical for development of a practice. Again, it's all about availability and affability. First in order to develop a practice, something that I wanted to ask you. Well you mentioned that you're gonna have the patients go back to their primary care physician. Most of I know we are gonna communicate with them, let them know how the patient is doing. However, we often refer the patient to a neuro oncologist and we assume that they're referring doctor we'll see them for their non oncological issues. So when you say make sure they go back, how do you control when they go back? If you're referring the post-op patient eventually to a neuro-oncologist at your local institution?

- So they always go back to see their primary care doctor just in general. But if they require specialized care that they don't have already, then of course they need to be seen within the institution. It's important to let the referring doctor know that, "Hey, diagnosis was a high grade glioma. We'll be seeing our medical neuro-oncology team and radiation oncology team next week." No one is gonna have a problem with that. I think the main take home point there is that, many times we are referred patients by a specialist. So a radiation oncologist will send us a case of radiation necrosis or an oncologist will send us a met or a neurologist will send us whatever. And if you take care of that patient and you send it to a university specialist when it came from a private specialist, that's where you can start to make enemies and you can start losing referrals.

- All right, what you're saying is that don't refer a patient who came from an endocrinologist to your endocrinologist.

- Correct.

- But what do you do in a case that an endocrinologist refers you a patient and you figure out the workup is not complete and requires higher expertise, especially for Cushing patients that could be questionable workup. How would you handle those political situations?

- So that's excellent question and I totally agree with you. My policy is that for Cushings, which as is very complex, I tell anyone who sends me a patient with Cushings, "Happy to see your patient." I see them I say, "It looks like this patient has Cushings. Just so you know, our policy is they always get seen by a specialized neuroendocrinologist here to verify 'cause that's just policy. And then I operate and they always go back to the other doctor." So that's just policy. If it's Cushings, I will tell that endocrinologist, "Great workup." And I tell them, "Do you mind if they see our neuroendocrinologist?" 99\100, they actually are totally fine with that because Cushings can be very overwhelming. When they see our neuroendocrinologist nine out of 10 times they say, "Yes, it's Cushing's proceed." Every now and then they'll say, "There's further workup needed." At which point I'll put the two endocrinologists in touch with one another and they'll very politely be like, "You did A, B, C and D, but you need EF F and G and then it gets done." So Cushing operate unless it's verified by one of our endocrinologists.

- Right, well starting to coordinate care of the patient for other physicians can be quite overwhelming when you have a busy practice. So I respect a lot of what you're saying, but there's part of the stuff that you mentioned that can become overwhelming. And may not be practical. Absolutely, what you said makes sense. I think 80, 90% of what you refer to is critical. However, there's gonna be a portion of them that for a quality of life of a surgeon, it's important to know that you cannot do everything. You cannot necessarily send an image to every referring doctor. I mean, you have fellows who do that. Unfortunately I'm unable to make my fellows do that. So I need a secret sauce behind that. And so there is some amount of administrative work that may overwhelm you. If you start really doing those kind of things, it would interfere with your other activities. And if you say that I'm gonna do everything, then the quality of life for sure will suffer. So I wanna be real to practical for everyone and say that, yes, what you're doing makes great sense. But is it possible in every scenario? I think it has to be approached in a selective manner to make it practical with a lifestyle that is amenable to other responsibilities we often have. Does that make sense to you?

- Oh, 100%. And I totally agree with that. I'm very lucky in the situation that I have here with the team that we've assembled to be able to do what my talk just went over. But I know that my situation here at Miami is very unique. I don't think this can be done everywhere by everyone. And so I would say that these techniques are things that people should incorporate as best they can. You can do it 100% or 20%, whatever works for you, whatever's feasible in whatever situation you're in. These are just pearls that I think people should select how they wanna use it and how much they wanna integrate. But yeah, of course it's a ton of work and it depends on what are your priorities and how well you can integrate this into the rest of your life.

- Right, and as you know, this becomes so complicated that I personally went and got an MBA. So I highly recommend people get an MBA. I almost feel, and maybe I'm a little bit dogmatic about that, that developing a high level practice and working with an extremely socioeconomically complex healthcare system that would only become much more complex in a very near future will require a great understanding of business principles. So I always say if you are planning to be in a large private practice or be very successful referral wise or business wise or practice wise in academics, you have to have an MBA. There's just no way around it. There's just so many complex socioeconomic issues that are approaching us in the next two years that I think we will find that practicing neurosurgery is going to be significantly more complex. It doesn't mean that we shouldn't enjoy neurosurgery. I think we're gonna very soon find out that enjoying neurosurgery is gonna be a lot more difficult and the fact that being in the OR is gonna become even more and more the easiest part of our career. Don't you agree with that?

- I could not say it better myself. I'm sure you remember back when you were a resident, you focus on neurosurgery. Wow, being a neurosurgeon is operating on the brain or operating on the spine. And you think that the OR is like all you do. And based on what I do, the OR is less than half of what I do. And I'm sure it's the same for you. To be successful in neurosurgery, your time in the OR is an important yet small part of what it takes to be successful in neurosurgery. The people that are successful now, and especially the people that are gonna be successful 10 years from now and 20 years from now, are gonna bring a whole different skillset than just neurosurgery. It is a business sense, it is a social sense, it's a networking sense, it's an organizational sense, it's a practical sense. All that stuff is so critical to being successful, not only individually, but being a leader, building a program, being program director, chairman, whatever it's gonna be, that skillset is so greater than just what's in the operating room.

- So well said. I definitely less than 50% of my work is in operating room. Very, very well said. And this brings up to a closure. A very important one. Harvey Cushing in 1923, in a peak of his career, made a statement and stands so true today when he said, "I would lie or I would dream one day to see a neurosurgery chief somewhere without arms as neurosurgery is the least part of the job." He eloquently said that. He really said I would love to see a chief somewhere in neurosurgery who doesn't have arms, because neurosurgical part is the least part of our work. We have to keep that in mind. Unfortunately, most studies are not taught during residency. Not at all, zero. And most neurosurgery residents feel that neurosurgery is operating, it is not. There's so many more elements to it, so many and so eloquently mentioned by you. So I could not be more proud Ric, What you have accomplished. Incredible surgeon, leader, communicator, really a future star of neurosurgery. You're a star now. We're gonna probably hear more of your stardom more and more and I'm so proud of that. Keep up the great work. And we would love to have you with us again in near future.

- Thanks, Aaron. It would be a pleasure. And again, thanks for the invite. Phenomenal program you have.

- Thank you, God bless you. Thank you.

- Take care, likewise.

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